1902809197 NPI number — DR. JEFFREY S DOME MD

Table of content: DR. JEFFREY S DOME MD (NPI 1902809197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902809197 NPI number — DR. JEFFREY S DOME MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOME
Provider First Name:
JEFFREY
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902809197
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 37215
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21297-3215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 MICHIGAN AVE NW
Provider Second Line Business Practice Location Address:
CHILDREN'S NATIONAL MEDICAL CENTER
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20010-2916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-476-2800
Provider Business Practice Location Address Fax Number:
202-476-5685
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0207X , with the licence number:  MD036384 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3821464 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 422400000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00119084 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104788409 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2045058 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009912830 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1135554 00 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 133502001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1548669 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 804006 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0030431 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010017688 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0527630 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060474601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 205027006 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64928674 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7612398 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: F94483 . This is a "UPIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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